Healthcare Provider Details

I. General information

NPI: 1447040027
Provider Name (Legal Business Name): JESSICA BODNAR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2025
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2043 COLLEGE WAY
FOREST GROVE OR
97116-1797
US

IV. Provider business mailing address

115 SE 143RD AVE
PORTLAND OR
97233-2113
US

V. Phone/Fax

Practice location:
  • Phone: 503-352-6151
  • Fax:
Mailing address:
  • Phone: 503-954-5647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberATI4830
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: